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Background: There is debate as to whether recurrent biliary complications are more common in patients who do not have elective cholecystectomy after endoscopic retrograde cholangiopancreatography (ERCP) management of common bile duct (CBD) stones. The aim of this study was to determine the fate of patients with intact gallbladders who have had CBD stones removed at ERCP, and to assess their risk of recurrent biliary symptoms.Methods: We retrospectively identified all patients in our large tertiary center population with intact gallbladders who had an ERCP for CBD stones from December 1999 to March 2002. We determined which patients had subsequent elective cholecystectomy, and the outcomes of patients who did not have elective surgery.Results: 309 patients had CBD stones at ERCP during the study period, of which 139 had intact gallbladders at the time of ERCP. Of these 139 patients 59 had subsequent elective cholecystectomy, 11 by open operation and 48 laparoscopically. Of these 139 patients, 27 had cholecystectomy planned; 47 patients were managed with a wait-and-see strategy, 30 of whom were poor surgical candidates. Of these 47 patients in whom a wait-and-see policy was adopted, 9 (19%) developed complications including recurrent pain and/or abnormal liver function tests (LFTs), recurrent biliary colic, and pancreatitis. Eight of these nine patients were from the poor surgical candidate group. Sphincterotomy had been performed at initial ERCP in all patients.Conclusions: Over half of our population of 139 patients with CBD stones at ERCP and intact gallbladders had actual or planned elective cholecystectomy. For those patients in whom a decision to wait-and-see was made, almost 20% developed complications. Elective cholecystectomy after a finding of choledocholithiasis is supported by many and is a common strategy in our experience. Recurrent biliary complications are relatively common in those who do not undergo elective cholecystectomy, especially those patients who represent a high operative risk. [ABSTRACT FROM AUTHOR]

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is a technically demanding procedure that can cause substantial complications. Competence in performing ERCP and the learning curve for achieving competence are poorly understood.Objective: To evaluate the number of supervised ERCPs that physicians must do to achieve procedural competence. Competence was defined as a 0.8 probability of successfully completing specific technical components of ERCP and an overall grading of competence as judged by the attending physician.Design: Prospective study.Setting: University training program for gastroenterologists.Participants: 17 gastroenterology fellows at various stages of training.Measures: Experienced therapeutic endoscopists prospectively graded gastroenterology fellows during 1796 consecutive ERCPs. Fellows were graded on their overall level of competence for the procedure and on specific technical components of ERCP.Results: Grading data were available for 1450 ERCPs (81%). The number of ERCPs done before adequate skill was achieved was 160 for cholangiography, 140 for pancreatography, 160 for deep cannulation of the pancreatic duct, 120 for stone extraction, and 60 for stent insertion. Fellows achieved overall competence after completing 180 to 200 ERCPs. The predicted probability of overall competence was 0.8 after 137 ERCPs and 0.9 after 185 ERCPs.Conclusions: At least 180 ERCPs were required before these gastroenterology fellows could be considered competent in ERCP. This number is much greater than that previously recommended, and these findings have substantial implications for training guidelines and issues of competence and certification in ERCP. The methods used to define and evaluate competence in ERCP could also be used to assess competence in other medical procedures. [ABSTRACT FROM AUTHOR]

Communities are increasingly interested in primary prevention efforts to reduce health inequities. However, few communities can access local data on social determinants of health and many do not have the skills or training to interpret data to inform decision making on appropriate strategies that impact social determinants of health. A population-based youth health survey administered to middle and high school students, such as exists in most states in the United States, can assess health behaviors and risk and protective factors. The schools and school districts that participate are provided with reports of results and data interpretation resources that support their understanding of risk and protective factors to inform local decision making and action. Other states can similarly provide local data and resources on risk and protective factors to help communities collaborate on primary prevention efforts that achieve health equity., Competing Interests: The authors have no potential conflicts of interest to disclose., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc.)

A February 3, 2023 train derailment and subsequent burn released hazardous chemicals into East Palestine, Ohio. One potential exposure was polychlorinated dibenzo-p-dioxins, dibenzofurans, and coplanar polychlorinated biphenyls (cPCBs), collectively referred to as dioxins. Many studies have linked dioxins to numerous health effects. A pilot study was conducted July 17-18, 2023 to assess residents' serum dioxin levels. Eighteen persons who were White, nonsmokers with a mean age of 55, and 56% female, provided serum for analysis. Measurement of 20 dioxins, furans, and cPCBs congeners was conducted using gas chromatography, isotope dilution, and high-resolution mass spectrometry. A toxic equivalency (TEQ) value for each participant was calculated by multiplying the reported concentration of each congener by its toxic equivalency factor and summing the results. TEQs were compared to 2011-2012 National Health and Nutrition Examination Survey (NHANES) data by race/ethnicity, sex, and age group. All participants had serum TEQ values either below or within the range of NHANES values. Mean TEQ values were lower in younger age groups; we observed no sex-specific differences. These pilot data demonstrate that although dioxins may have formed during the derailment, exposures to participants did not increase their TEQ values compared with 2011-2012 NHANES., Competing Interests: The authors declare no competing financial interest.

Purpose/objectives: The Centers for Disease Control and Prevention has highlighted the strong association between healthcare-associated infections and the reprocessing of flexible endoscopes. This process improvement project provided an evidence-based workflow analysis of pleuravideoscope reprocessing to validate and implement safe practices in the pulmonary clinic and sterile processing department., Description of the Project/program: A multidisciplinary team created an audit tool to complete infection control risk assessment using Lean Six Sigma methodology., Outcome: The risk assessment identified gaps in clinical practice, prompting corrective measures using a shared decision-making approach. The organization updated standard operating procedures, provided training and competency assessments, and purchased single-use pleuravideoscopes. These initiatives addressed the deficiencies and reinforced a culture of continuous process improvement and patient safety., Conclusion: Multidisciplinary teams should perform comprehensive reviews of facility processes and assess the risks related to infection control to identify optimal pleuravideoscope workflows for the healthcare institution. The involvement of a clinical nurse specialist is advantageous, as they possess the expertise necessary to facilitate collaborative efforts among team members spanning various departments. By leveraging the insights and skills of diverse professionals, healthcare organizations can optimize their reprocessing programs and enhance patient safety., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a “work of the United States Government” for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government.)

Background: Certain product characteristics, such as flavor, may increase adolescents' willingness to try vaped nicotine and cannabis (marijuana) products., Methods: A discrete choice experiment embedded within the 2021-2022 California Teens Nicotine and Tobacco Project Online Survey was administered to a non-probability sample of N = 2342 adolescents ages 12-17. Participants were sequentially presented four randomly-generated pairs of hypothetical vape products that varied in device type (disposable, refillable), content (nicotine, marijuana, "just vapor"), and flavor (seven options) and asked which of these (or neither) they would be more willing to try if a best friend offered. Conditional logistic regression quantified associations between product characteristics and participants' selections, including interactions by past 30-day use of e-cigarettes, marijuana, or both., Results: Candy/dessert, fruit, and fruit-ice combination flavors were all associated with greater willingness to try a vape product (versus tobacco flavor) among participants not using e-cigarettes or marijuana, those using only e-cigarettes, and those co-using e-cigarettes and marijuana. Among participants only using marijuana, the most preferred flavors were no flavor, candy/dessert, and icy/frost/menthol. Among participants not using e-cigarettes or marijuana, model-predicted willingness to try a displayed vape product was greater when products were sweet or fruit flavored than tobacco or unflavored, regardless of whether displayed options contained nicotine (fruit/sweet: 21 %, tobacco/unflavored: 4 %), marijuana (fruit/sweet: 18 %, tobacco/unflavored: 6 %), or "just vapor" (fruit/sweet: 29 %, tobacco/unflavored: 16 %)., Conclusions: In this online non-probability sample, flavors in nicotine and cannabis vape products increased adolescents' willingness to try them. Comprehensive bans on flavored vapes would likely reduce adolescent use., Competing Interests: Conflict of Interest Statement The authors report that there no conflicts to disclose., (Copyright © 2023 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Despite the presence of stomata in leaves, foliar application of agrochemicals can be extremely inefficient due to the low permeability of leaf cuticular surfaces to polar compounds. Methods: This study introduced a laser-based "wax exfoliation" method to facilitate the penetration of substances into the leaf and, together with enhancing their uptake into the phloem and subsequent transport across tissue. This investigation demonstrated the effectiveness and non-invasive properties of laser exfoliation to improve the penetration of foliar-applied substances into citrus leaves. Results: This work presents the use of laser energy to exfoliate the cuticle of a leaf, with the highest energy density of 0.76 J/ cm2 resulting in 85-90% exfoliation across the entire laser-spot area. The infrared wavelength of the erbium laser is specifically chosen to target the wax cuticle without causing damage to the underlying epidermal cells. This selective ablation allows for increased penetration of therapeutic compounds into the leaf and transportation throughout the plant's vasculature. This is demonstrated using a fluorescent glucose analog applied to the laser treated leaves, showing increased penetration and transport throughout the leaf. Conclusions: Our findings demonstrate that the use of laser technology for the foliar application of agrochemicals provides significant advantages, including improved foliage uptake of therapeutic compounds. The method of cuticle exfoliation presented in this study is highly effective and non-intrusive, limiting its effects to the cuticle only. Future work should focus on the development of prototypes for in-field applications, including testing at longer distances as the Er:YAG laser does not require a lens for this application., Competing Interests: Competing interests: The authors declare that a patent application has been filed for the method described in this manuscript. The patent application number is 16/529138. The authors confirm that the details of the method described in this manuscript are sufficient for reproducibility., (Copyright: © 2023 Ponce Cabrera L et al.)

Immersive virtual reality computer programs provide new experimental and treatment interventions that hold great promise for nursing. Immersive virtual reality uses sensory cues to represent real-world environments in a way that makes participants feel as if they are in a physical space different from the one in which they currently exist. As the acceptance of immersive virtual reality as a clinical and experimental tool has grown, so has the need to ensure that the context depicted in the environment mirrors both the sensory and the task requirements of the real-world situation. Here, we describe the use of nurse expert key informant group interviews to generate requirements that must be fulfilled in immersive virtual reality environments designed to evoke and engage participants in self-management tasks. An expert panel of four home care nurses participated in three sessions designed to elicit details of common home care challenges, frequency of variation, and typical participants. More than 20 potential scenarios were identified. The design team later used this information to create design requirements for two key scenarios and subsequently develop immersive virtual reality environments for use in research studies, mapping sensory and functional expectations to immersive virtual reality implementations. Challenges in mapping from key informant group findings to requirements are addressed., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

The adaptation mechanisms of microbial communities to natural perturbations remain unexplored, particularly in extreme environments. The extremophilic communities of halite (NaCl) nodules from the hyper-arid core of the Atacama Desert are self-sustained and represent a unique opportunity to study functional adaptations and community dynamics with changing environmental conditions. We transplanted halite nodules to different sites in the desert and investigated how their taxonomic, cellular, and biochemical changes correlated with water availability, using environmental data modeling and metagenomic analyses. Salt-in strategists, mainly represented by haloarchaea, significantly increased in relative abundance at sites characterized by extreme dryness, multiple wet/dry cycles, and colder conditions. The functional analysis of metagenome-assembled genomes (MAGs) revealed site-specific enrichments in archaeal MAGs encoding for the uptake of various compatible solutes and for glycerol utilization. These findings suggest that opportunistic salt-in strategists took over the halite communities at the driest sites. They most likely benefited from compounds newly released in the environment by the death of microorganisms least adapted to the new conditions. The observed changes were consistent with the need to maximize cellular bioenergetics when confronted with lower water availability and higher salinity, providing valuable information on microbial community adaptations and resilience to climate change., (© 2022. The Author(s).)

We use stochastic simulations to investigate the performance of two recently developed methods for calculating the free energy profiles of ion channels and their electrophysiological properties, such as current-voltage dependence and reversal potential, from molecular dynamics simulations at a single applied voltage. These methods require neither knowledge of the diffusivity nor simulations at multiple voltages, which greatly reduces the computational effort required to probe the electrophysiological properties of ion channels. They can be used to determine the free energy profiles from either forward or backward one-sided properties of ions in the channel, such as ion fluxes, density profiles, committor probabilities, or from their two-sided combination. By generating large sets of stochastic trajectories, which are individually designed to mimic the molecular dynamics crossing statistics of models of channels of trichotoxin, p7 from hepatitis C and a bacterial homolog of the pentameric ligand-gated ion channel, GLIC, we find that the free energy profiles obtained from stochastic simulations corresponding to molecular dynamics simulations of even a modest length are burdened with statistical errors of only 0.3 kcal/mol. Even with many crossing events, applying two-sided formulas substantially reduces statistical errors compared to one-sided formulas. With a properly chosen reference voltage, the current-voltage curves can be reproduced with good accuracy from simulations at a single voltage in a range extending for over 200 mV. If possible, the reference voltages should be chosen not simply to drive a large current in one direction, but to observe crossing events in both directions.

Newborn screening (NBS) laboratories cannot accurately compare mass spectrometry-derived results and cutoff values due to differences in testing methodologies. The objective of this study was to assess harmonization of laboratory proficiency test (PT) results using quality control (QC) data. Newborn Screening Quality Assurance Program (NSQAP) QC and PT data reported from 302 laboratories in 2019 were used to compare results among laboratories. QC materials were provided as dried blood spot cards which included a base pool and the base pool enriched with specific concentrations of metabolites in a linear range. QC data reported by laboratories were regressed on QC data reported by the Centers for Disease Control and Prevention (CDC), and laboratory's regression parameters were used to harmonize their PT result. In general, harmonization tended to reduce overall variation in PT data across laboratories. The metabolites glutarylcarnitine (C5DC), tyrosine, and phenylalanine were displayed to highlight inter- and intra-method variability in NBS results. Several limitations were identified using retrospective data for harmonization, and future studies will address these limitations to further assess feasibility of using NSQAP QC data to harmonize PT data. Harmonizing NBS data using common QC materials appears promising to aid result comparison between laboratories., Competing Interests: Conflicts of InterestThe authors declare no conflict of interest., (© 2020 by the authors.)

A method is presented for estimating frequency responses of multiple-input multiple-output bare-airframe dynamics from flight test data containing feedback control and/or mixing of control effectors. Orthogonal phase-optimized multisines are used to simultaneously excite each input with unique harmonic frequencies, at which frequency responses are computed as ratios of output-to-input Fourier transform data. The confounding effects of feedback and mixing are resolved by interpolation of the frequency responses. The analysis can be run in batch for post-flight analysis, or in real time as the aircraft is flying. The effectiveness of the method was verified using simulations of the subscale T-2 generic transport airplane with rate feedback. The method was also demonstrated using flight test data from the X-56A MUTT aeroelastic airplane, which was flown with both feedback control and mixing.

In order to facilitate studies on the impact of the space environment on biological systems, we have developed a prototype of GEMM (Gene Expression Measurement Module) - an automated, miniaturized, integrated fluidic system for in-situ measurements of gene expression in microbial samples. The GEMM instrument is capable of (1) lysing bacterial cell walls, (2) extracting and purifying RNA released from cells, (3) hybridizing the RNA to probes attached to a microarray and (4) providing electrochemical readout, all in a microfluidics cartridge. To function on small, uncrewed spacecraft, the conventional, laboratory protocols for both sample preparation and hybridization required significant modifications. Biological validation of the instrument was carried out on Synechococcus elongatus, a photosynthetic cyanobacterium known for its metabolic diversity and resilience to adverse conditions. It was demonstrated that GEMM yielded reliable, reproducible gene expression profiles. GEMM is the only high throughput instrument that can be deployed in near future on space platforms other than the ISS to advance biological research in space. It can also prove useful for numerous terrestrial applications in the field., (Copyright © 2019. Published by Elsevier Ltd.)

Objectives: To investigate the proportion of documented ultrasound findings that were unsupported by stored ultrasound images in the obstetric ultrasound unit, before and after the implementation of a quality improvement process consisting of a checklist and feedback., Methods: A quality improvement process was created involving utilization of a checklist and feedback from physician to sonographer. The feedback was based on findings of the physician's review of the report and images using a check list. To assess the impact of this process, two groups were compared. Group 1 consisted of 58 ultrasound reports created prior to initiation of the process. Group 2 included 65 ultrasound reports created after process implementation. Each chart was reviewed by a physician and a sonographer. Findings considered unsupported by stored images by both reviewers were used for analysis, and the proportion of unsupported findings was compared between the two groups. Results are expressed as mean ± standard error. A p value of < .05 was used to determine statistical significance., Results: Univariate analysis of baseline characteristics and potential confounders showed no statistically significant difference between the groups. The mean proportion of unsupported findings in Group 1 was 5.1 ± 0.87, with Group 2 having a significantly lower proportion (2.6 ± 0.62) (p value = .018)., Conclusions: Results suggest a significant decrease in the proportion of unsupported findings in ultrasound reports after quality improvement process implementation. Thus, we present a simple yet effective quality improvement process to reduce unsupported ultrasound findings.

Objectives: During 2010-2014, the Centers for Disease Control and Prevention implemented the National Public Health Improvement Initiative (NPHII) to assist 73 public health agencies in conducting activities to increase accreditation readiness, improve efficiency and effectiveness through quality improvement, and increase performance management capacity. A summative evaluation of NPHII was conducted to examine whether awardees met the initiative's objectives, including increasing readiness for accreditation., Design: A nonexperimental, utilization-focused evaluation with a multistrand, sequential mixed-methods approach was conducted to monitor awardee accomplishments and activities. Data analysis included descriptive statistics, as well as subanalyses of data by awardee characteristics. Thematic analysis using deductive a priori codes was used for qualitative analysis., Results: Ninety percent of awardees reported completing at least 1 accreditation prerequisite during NPHII, and more than half reported completing all 3 prerequisites by the end of the program. Three-fourths of awardees that completed a self-assessment reported closing gaps for at least 1 Public Health Accreditation Board (PHAB) standard. Within 3 years of the launch of PHAB accreditation, 7 NPHII awardees were accredited; another 38 had formally applied for accreditation., Conclusions: Through NPHII, awardees increased collaborative efforts around accreditation readiness, accelerated timelines for preparing for accreditation, and prioritized the completion of required accreditation activities.

Context: The Center of Disease Control and Prevention's Core State Violence and Injury Prevention Program (Core SVIPP) provides an opportunity for states to engage with their partners to implement, evaluate, and disseminate strategies that lead to the reduction and prevention of injury and violence. Core SVIPP requires awardees to develop or update their state injury and violence plans. Currently, literature informing state planning efforts is limited, especially regarding materials related to injury and violence. Presumably, plans that are higher quality result in having a greater impact on preventing injury and violence, and literature to improve quality would benefit prevention programming., Objective: (1) To create a comprehensive injury-specific index to aid in the development and revision of state injury and violence prevention plans, and (2) to assess the reliability and utility of this index., Design: Through an iterative development process, a workgroup of subject matter experts created the Violence and Injury Prevention: Comprehensive Index Tool (VIP:CIT). The tool was pilot tested on 3 state injury and violence prevention plans and assessed for initial usability. Following revisions to the tool (ie, a rubric was developed to further delineate consistent criteria for rating; items were added and clarified), the same state plans were reassessed to test interrater reliability and tool utility., Results: For the second assessment, reliability of the VIP:CIT improved, indicating that the rubric was a useful addition. Qualitative feedback from states suggested that the tool significantly helped guide plan development and communicate about planning processes., Conclusion: The final VIP:CIT is a tool that can help increase plan quality, decrease the research-to-practice gap, and increase connectivity to emerging public health paradigms. The tool provides an example of tailoring guidance materials to reflect academic literature, and it can be easily adapted to other topic areas to promote quality of strategic plans for numerous outcomes.

The bacterial effector harpin induces the transcription of the Arabidopsis thaliana NON-RACE SPECIFIC DISEASE RESISTANCE 1/HARPIN INDUCED1 (NDR1/HIN1) coiled-coil nucleotide binding leucine rich repeat (CC-NB-LRR) defense signaling gene. In Glycine max, Gm-NDR1-1 transcripts have been detected within root cells undergoing a natural resistant reaction to parasitism by the syncytium-forming nematode Heterodera glycines, functioning in the defense response. Expressing Gm-NDR1-1 in Gossypium hirsutum leads to resistance to Meloidogyne incognita parasitism. In experiments presented here, the heterologous expression of Gm-NDR1-1 in G. hirsutum impairs Rotylenchulus reniformis parasitism. These results are consistent with the hypothesis that Gm-NDR1-1 expression functions broadly in generating a defense response. To examine a possible relationship with harpin, G. max plants topically treated with harpin result in induction of the transcription of Gm-NDR1-1. The result indicates the topical treatment of plants with harpin, itself, may lead to impaired nematode parasitism. Topical harpin treatments are shown to impair G. max parasitism by H. glycines, M. incognita and R. reniformis and G. hirsutum parasitism by M. incognita and R. reniformis. How harpin could function in defense has been examined in experiments showing it also induces transcription of G. max homologs of the proven defense genes ENHANCED DISEASE SUSCEPTIBILITY1 (EDS1), TGA2, galactinol synthase, reticuline oxidase, xyloglucan endotransglycosylase/hydrolase, alpha soluble N-ethylmaleimide-sensitive fusion protein (α-SNAP) and serine hydroxymethyltransferase (SHMT). In contrast, other defense genes are not directly transcriptionally activated by harpin. The results indicate harpin induces pathogen associated molecular pattern (PAMP) triggered immunity (PTI) and effector-triggered immunity (ETI) defense processes in the root, activating defense to parasitic nematodes., (Copyright © 2017. Published by Elsevier Masson SAS.)

Three different types of maneuvers were designed to separately quantify pitch rate and angle of attack rate contributions to the nondimensional aerodynamic pitching moment coefficient. These maneuvers combined pilot inputs and automatic multisine excitations, and were demonstrated with the subscale T-2 and Bat-4 airplanes using the NASA AirSTAR flight test facility. Stability and control derivatives, in particular C m q and C m α ˙ , were accurately estimated from the flight test data. These maneuvers can be performed with many types of aircraft, and the results can be used to improve physical insight into the flight dynamics, facilitate more accurate comparisons with wind tunnel experiments or numerical investigations, and increase simulation prediction fidelity.

Almost all modern proteins possess well-defined, relatively rigid scaffolds that provide structural preorganization for desired functions. Such scaffolds require the sufficient length of a polypeptide chain and extensive evolutionary optimization. How ancestral proteins attained functionality, even though they were most likely markedly smaller than their contemporary descendants, remains a major, unresolved question in the origin of life. On the basis of evidence from experiments and computer simulations, we argue that at least some of the earliest water-soluble and membrane proteins were markedly more flexible than their modern counterparts. As an example, we consider a small, evolved in vitro ligase, based on a novel architecture that may be the archetype of primordial enzymes. The protein does not contain a hydrophobic core or conventional elements of the secondary structure characteristic of modern water-soluble proteins, but instead is built of a flexible, catalytic loop supported by a small hydrophilic core containing zinc atoms. It appears that disorder in the polypeptide chain imparts robustness to mutations in the protein core. Simple ion channels, likely the earliest membrane protein assemblies, could also be quite flexible, but still retain their functionality, again in contrast to their modern descendants. This is demonstrated in the example of antiamoebin, which can serve as a useful model of small peptides forming ancestral ion channels. Common features of the earliest, functional protein architectures discussed here include not only their flexibility, but also a low level of evolutionary optimization and heterogeneity in amino acid composition and, possibly, the type of peptide bonds in the protein backbone., Competing Interests: The authors declare no conflict of interest.

We examine the validity and utility of the electrodiffusion (ED) equation, i.e., the generalized Nernst-Planck equation, to characterize, in combination with molecular dynamics, the electrophysiological behavior of simple ion channels. As models, we consider three systems-two naturally occurring channels formed by α-helical bundles of peptaibols, trichotoxin, and alamethicin, and a synthetic, hexameric channel, formed by a peptide that contains only leucine and serine. All these channels mediate transport of potassium and chloride ions. Starting with equilibrium properties, such as the potential of mean force experienced by an ion traversing the channel and diffusivity, obtained from molecular dynamics simulations, the ED equation can be used to determine the full current-voltage dependence with modest or no additional effort. The potential of mean force can be obtained not only from equilibrium simulations, but also, with comparable accuracy, from nonequilibrium simulations at a single voltage. The main assumptions underlying the ED equation appear to hold well for the channels and voltages studied here. To expand the utility of the ED equation, we examine what are the necessary and sufficient conditions for Ohmic and nonrectifying behavior and relate deviations from this behavior to the shape of the ionic potential of mean force.

Aim: To evaluate the success rates of performing therapy utilizing a rotational assisted enteroscopy device in endoscopic retrograde cholangiopancreatography (ERCP) in surgically altered anatomy patients., Methods: Between June 1, 2009 and November 8, 2012, we performed 42 ERCPs with the use of rotational enteroscopy for patients with altered anatomy (39 with gastric bypass Roux-en-Y, 2 with Billroth II gastrectomy, and 1 with hepaticojejunostomy associated with liver transplant). The indications for ERCP were: choledocholithiasis: 13 of 42 (30.9%), biliary obstruction suggested on imaging: 20 of 42 (47.6%), suspected sphincter of Oddi dysfunction: 4 of 42 (9.5%), abnormal liver enzymes: 1 of 42 (2.4%), ascending cholangitis: 2 of 42 (4.8%), and bile leak: 2 of 42 (4.8%). All procedures were completed with the Olympus SIF-Q180 enteroscope and the Endo-Ease Discovery SB overtube produced by Spirus Medical., Results: Successful visualization of the major ampulla was accomplished in 32 of 42 procedures (76.2%). Cannulation of the bile duct was successful in 26 of 32 procedures reaching the major ampulla (81.3%). Successful therapeutic intervention was completed in 24 of 26 procedures in which the bile duct was cannulated (92.3%). The overall intention to treat success rate was 64.3%. In terms of cannulation success, the intention to treat success rate was 61.5%. Ten out of forty two patients (23.8%) required admission to the hospital after procedure for abdominal pain and nausea, and 3 of those 10 patients (7.1%) had a diagnosis of post-ERCP pancreatitis. The average hospital stay was 3 d., Conclusion: It is reasonable to consider an attempt at rotational assisted ERCP prior to a surgical intervention to alleviate biliary complications in patients with altered surgical anatomy.

Objective: To assess California firefighters' blood concentrations of selected chemicals and compare with a representative US population., Methods: We report laboratory methods and analytic results for cadmium, lead, mercury, and manganese in whole blood and 12 serum perfluorinated chemicals in a sample of 101 Southern California firefighters., Results: Firefighters' blood metal concentrations were all similar to or lower than the National Health and Nutrition Examination Survey (NHANES) values, except for six participants whose mercury concentrations (range: 9.79 to 13.42 μg/L) were close to or higher than the NHANES reporting threshold of 10 μg/L. Perfluorodecanoic acid concentrations were elevated compared with NHANES and other firefighter studies., Conclusions: Perfluorodecanoic acid concentrations were three times higher in this firefighter group than in NHANES adult males. Firefighters may have unidentified sources of occupational exposure to perfluorinated chemicals.

Establishing the relation between the structures and functions of protein ion channels, which are protein assemblies that facilitate transmembrane ion transport through water-filled pores, is at the forefront of biological and medical sciences. A reliable way to determine whether our understanding of this relation is satisfactory is to reproduce the measured ionic conductance over a broad range of applied voltages. This can be done in molecular dynamics simulations by way of applying an external electric field to the system and counting the number of ions that traverse the channel per unit time. Since this approach is computationally very expensive we develop a markedly more efficient alternative in which molecular dynamics is combined with an electrodiffusion equation. This alternative approach applies if steady-state ion transport through channels can be described with sufficient accuracy by the one-dimensional diffusion equation in the potential given by the free energy profile and applied voltage. The theory refers only to line densities of ions in the channel and, therefore, avoids ambiguities related to determining the surface area of the channel near its endpoints or other procedures connecting the line and bulk ion densities. We apply the theory to a simple, model system based on the trichotoxin channel. We test the assumptions of the electrodiffusion equation, and determine the precision and consistency of the calculated conductance. We demonstrate that it is possible to calculate current/voltage dependence and accurately reconstruct the underlying (equilibrium) free energy profile, all from molecular dynamics simulations at a single voltage. The approach developed here applies to other channels that satisfy the conditions of the electrodiffusion equation.

Objectives: To study potential exposures to crystalline silica and the number of work-related cases of silicosis occurring in Alberta., Methods: Exposure data comprising 343 occupational samples were collected at 40 worksites across 13 industries. To assess silicosis reporting, cases reported to the Alberta government, claims accepted by the Workers' Compensation Board for work-related silicosis, and billings to Alberta Health for medical services with a diagnostic code for silicosis during a similar time period were compared., Results: Workers potentially over-exposed to airborne respirable crystalline silica were identified at most of the worksites evaluated. There were large discrepancies in the number of silicosis cases found., Conclusions: Many Alberta workers may be over-exposed to airborne respirable crystalline silica, and the incidence of work-related silicosis in Alberta may not be adequately represented by the official statistics.

The Higher Education Center in third-world countries is in charge of training competent manpower as well as science production, thereby widely affecting the society's cultural, political, and social affairs. Therefore, to survive and adapt to the environment, higher education needs personnel who function in accordance with today's evolving world. One of the ways to adapt is to shift to the form of learning organization. This study reports on a descriptive field study conducted on 499 university staff (208 from Shiraz University and 291 from Shiraz University of Medical Sciences). Data were collected using Sanga's learning-organization questionnaire. Face and content validities were determined using the academic staff's viewpoints, and reliability was proved to be 97%. According to the staff working in the 2 universities, the null hypothesis of the equality of the universities as to learning-organization indicators was rejected (0.05) because the significance level was less than 0.001. Therefore, there was a significant difference between these 2 universities in the aforementioned dimensions. The mean and total scores of the 5 indicators of the learning organization were higher for Shiraz University personnel as compared with those working in Shiraz University of Medical Sciences. Considering the important role of universities, it is necessary to take measures to promote learning-organization indicators to an ideal level, thereby contributing to our country's success and advancement.

Background: Moderate sedation is routinely performed in patients undergoing minor therapeutic and diagnostic procedures outside the operating room. The level of sedation is often monitored by sedation nurses using clinical criteria, such as sedation scores. The Bispectral Index (BIS) is derived from changes in the electroencephalograph profile that may provide an objective measure of the level of sedation. In this prospective observational study, we investigated whether using BIS values to guide sedative drug administration influences the level of sedation and the incidence of adverse events compared with using Ramsay sedation scale (RSS) only in nurse-administered moderate sedation. We hypothesized that both depth of sedation and the incidence of adverse events related to oversedation would decrease when sedation nurses used BIS values to help guide sedative drug administration., Methods: Sedation care was provided by trained sedation nurses under the supervision of a physician performing the procedure. The sedation regimen was initiated with IV midazolam 1 to 2 mg and fentanyl 50 mcg or hydromorphone 0.2 mg. Additional small boluses of midazolam, fentanyl, or hydromorphone were administered to maintain an RSS of 2 to 3 (cooperative, oriented, and responding to verbal command). Propofol was not used. Information including patient demographics, type of procedure, medication administered, RSS, and rates of adverse events was recorded by the sedation nurses for each patient on a computer-readable form. The study was divided into 3 phases. In phase 1 (baseline, 6 months' duration), baseline data on sedation practice were prospectively collected. There was no change from standard of care for all patients except that each patient had a BIS sensor attached, but the monitor was covered and nurses were blinded to the BIS values. In phase 2 (training, 3 months), the sedation nurses received comprehensive education on the use of BIS to guide sedative drug administration, pharmacology of commonly used drugs, and methods for rescue from oversedation. The recommended BIS range for moderate sedation was 75 to 90. Adequate training of all sedation nurses on the use of BIS was documented. In phase 3 (implementation, 6 months), the BIS values were used to guide drug administration., Results: Data were available on 1766 patients (999 and 767 patients in phases 1 and 3, respectively). Most of the procedures were colonoscopies, upper gastrointestinal endoscopies, examinations under anesthesia, endoscopic retrograde cholangiopancreatography, and central venous access catheter placements. No differences in the demographics between the 2 groups were observed. The RSS was inversely associated with the BIS value, r = -0.16 (95% confidence interval, -0.19 to -0.12; P < 0.00001). An RSS of 2 to 3 was maintained in 94% of patients in phase 1 and 96% of patients in phase 3 The mean (±SD) BIS values were 80.9 ± 6.8 in phase 1 and 80.4 ± 6.5 in phase 3. The number of sedation-related adverse events was lower in our sample when BIS was used, with an odds ratio of 0.41 (95% confidence interval, 0.28-0.62; P < 0.0001), and patients with restlessness had a lower BIS value than those without this symptom (P < 0.0001). No serious adverse events or deaths were reported., Conclusions: Nurse-administered moderate sedation using midazolam and fentanyl was usually associated with appropriate levels of sedation as assessed by both the RSS and BIS with an overall low incidence of adverse events. The use of BIS did not change the mean level of sedation significantly, although the number of sedation-related adverse events appears to be lower when BIS was used.

Background: Collaborations between academic institutions and state and local health departments have been shown to enhance the public health core functions of Assurance by improving the public health workforce's knowledge and skills. Few studies have analyzed how academic-health department collaborations enhance Assessment and Policy Development core functions. This qualitative study explores types of collaborations between health departments and Prevention Research Centers (PRCs) and how they align with the core functions. Prevention Research Centers are academic institutions funded by the Centers for Disease Control and Prevention to conduct public health research and translate research results for policies and practices., Methods: We reviewed each PRC's annual report from fiscal year 2011 and abstracted descriptions of PRC-health department collaborations. We identified 14 themes of PRC-health department collaborations and conducted a qualitative analysis to describe the dimensions and distribution of themes., Results: Of the 37 PRCs, 36 reported 215 collaborations with 19 city, 97 county, 31 state, and 46 tribal health departments. Themes of research, survey, and surveillance aligned with the Assessment core function and evaluation, strategic planning, technical assistance, and program implementation supported the Policy Development and Assurance core functions. Overall, health departments provided on-the-ground expertise to inform PRC research, ensuring its applicability to public health practice. Reciprocally, PRCs improved data quality, increased the scientific rigor of health department processes and programs, and filled knowledge gaps within health departments. Both PRCs and health departments enhanced the relevance of public health programs and practices by grounding implementation and evaluation in community needs and views., Conclusion: Findings from this study demonstrate that PRC-health department collaborations often enhanced multiple core functions that could lead to implementation of evidence-based interventions and continuous quality improvement of public health administration at the local, state, and tribal levels. This study highlights the value and importance of reciprocal academic-health department partnerships.

Introduction and Methods: Jail sentences and actual jail times were compared for 2006 California driving under the influence of alcohol or drugs (DUI) offenders from select counties using matched data from Department of Motor Vehicles (DMV), court, and sheriff databases. Additionally, alternative sanctions to jail were investigated., Results: Jail sentences reported by courts were consistently longer than actual jail time. Actual jail time percentages across participating counties ranged from 0 to 67% for 1st DUI offenders, 0 to 20% for 2nd offenders, and 0 to 66% for 3rd(+) offenders. Median percentages of jail sentences actually served across participating counties were 0%, 7%, and 22% for 1st, 2nd, and 3rd(+) DUI offenders, respectively. Alternative sentences were used more often for 1st DUI offenders and less so for 2nd and 3rd(+) offenders., Conclusions: Caution is warranted regarding conclusions about jail ineffectiveness as a DUI deterrent from previous studies given that most were based on jail sentence or statutory lengths, which appear to overestimate actual jail times., (© 2013.)

Aim: To compare efficacy and complications of partially covered self-expandable metal stent (pcSEMS) to plastic stent (PS) in patients treated for malignant, infrahilar biliary obstruction., Methods: Multicenter prospective randomized clinical trial with treatment allocation to a pcWallstent(®) (SEMS) or a 10 French PS. Palliative patients aged ≥ 18, for infrahilar malignant biliary obstruction and a Karnofsky performance scale index > 60% from 6 participating North American university centers. Primary endpoint was time to stent failure, with secondary outcomes of death, adverse events, Karnofsky performance score and short-form-36 scale administered on a three-monthly basis for up to 2 years. Survival analyses were performed for stent failure and death, with Cox proportional hazards regression models to determine significant predictive characteristics., Results: Eighty-five patients were accrued over 37 mo, 42 were randomized to the SEMS group and 83 patients were available for analyses. Time to stent failure was 385.3 ± 52.5 d in the SEMS and 153.3 ± 19.8 d in the PS group, P = 0.006. Time to death did not differ between groups (192.3 ± 23.4 d for SEMS vs 211.5 ± 28.0 d for PS, P = 0.70). The only significant predictor was treatment allocation, relating to the time to stent failure (P = 0.01). Amongst other measured outcomes, only cholangitis differed, being more common in the PS group (4.9% vs 24.5%, P = 0.029). The small number of patients in follow-up limits longitudinal assessments of performance and quality of life. From an initially planned 120 patients, only 85 patients were recruited., Conclusion: Partially covered SEMS result in a longer duration till stent failure without increased complication rates, yet without accompanying measurable benefits in survival, performance, or quality of life.